1. Assess for presence/absence of related factors or conditions that would preclude breastfeeding.Some conditions (e.g. certain maternal drugs, maternal HIV-positive
status, infant galactosemia) may preclude breastfeeding, in which case
the infant needs to be started on a safe alternative method of feeding
(Riordan, Auerbach, 2000; Lawrence, 2000).

2. Assess breast and nipple structure.Normal nipple and breast structure or early detection and treatment
of abnormalities with continuing support are important for successful
breastfeeding (Vogel, Hutchison, Mitchell, 1999).

3. Evaluate and record the mother's ability to position, give cues, and help the infant latch on.Correct positioning and getting the infant to latch on is critical
for getting breastfeeding off to a good start and contributes to
breastfeeding success (Duffy, Percival, Kershaw, 1997; Brandt, Andrews,
Kvale, 1998).

4. Evaluate and record the infant's ability to properly grasp and compress the areola with lips, tongue, and jaw.The infant must have a "competent suck" in order to achieve
successful breastfeeding. The jaws must compress the milk sinuses
beneath the areola. To do this the jaws must be well back on the areola
with the tongue over the lower gum, forming a trough around the breast,
and the lips must be flanged and sealed around the breast (Palmer,
VandenBerg, 1998; Lau, Hurst, 1999; Hill, Kurkowski, Garcia, 2000).

5. Evaluate and record the infant's suckling and swallowing pattern at the breast.When the infant sucks adequately, there is muscular movement visible
above the ears. When breast milk is actively flowing, infants suck at a
rate of once per second, and swallowing increases as milk supply
increases (Palmer, VandenBerg, 1998; Lau, Hurst, 1999; Hill, Kurkowski,
Garcia, 2000).

6. Evaluate and record signs of oxytocin release.The let-down reflex (tingling sensation in the breasts, milk dripping
from the breasts, and uterine cramping) is indication of oxytocin
release and is necessary for transfer of milk to the infant
(Uvnas-Moberg, Eriksson., 1996; Nissen et al, 1998; Neville, 1999).

7. Evaluate and record infant's state at the time of feeding.Infants breastfeed best when in the quiet-alert state. Difficulties
arise when trying to breastfeed a sleepy infant or a ravenously hungry
and crying infant (Brandt, Andrews, Kvale, 1998).

8. Assess knowledge regarding psychophysiology of lactation and specific treatment measures for underlying problems.Support and teaching must be individualized to the client's level of
understanding. The mother must acquire knowledge and become cognitively
and emotionally ready (Cox, Turnbull, 1998).

9. Assess psychosocial factors that may contribute to ineffective
breastfeeding (e.g., anxiety, goals and values/lifestyle that contribute
to ambivalence about breastfeeding).The attitude of the mother toward breastfeeding is critical in
achieving successful lactation, influencing milk production, and
facilitating the art of breastfeeding (Brandt, Andrews, Kvale, 1998).

10. Assess support person network.Social support is an important factor in successful breastfeeding (Trado, Hughes, 1996; Arlotti et al, 1998).

11. Promote comfort and relaxation to reduce pain and anxiety.Discomfort associated with breastfeeding can cause some women to
discontinue breastfeeding prematurely. Promoting comfort and relaxation
can lead to more successful breastfeeding (Lavergne, 1997).

12. Provide support by actively helping the mother to correctly position
the baby to attain a good latch on the nipple and encouraging her to
continue trying.Many problems that can lead to discontinuing breastfeeding can be
prevented by giving a high level of practical and emotional support to
the mother (Janken et al, 1999).

13. Bring infant to a quiet-alert state through alerting techniques
(e.g., provide variety in auditory, visual, and kinesthetic stimuli by
unwrapping the infant, placing the infant upright, or talking to the
infant) or consoling techniques as needed.A variety of stimuli can bring the infant to a quiet-alert state.
Repetition can soothe a crying baby, thus making it easier to initiate
breastfeeding (Brandt, Andrews, Kvale, 1998).

14. Enhance the flow of milk. Teach the mother to massage breast or burp
infant and switch to other breast when infant's swallowing slows down.The perception of inadequate milk supply can lead to early weaning.
Infants should breastfeed from both breasts at each feeding. Breast
massage can enhance the flow of milk and stimulate production (Riordan,
Auerbach, 2000).

15. Evaluate adequacy of infant intake.Infant intake can be measured by objective criteria such as number
and quality of feedings, infant elimination and weight gain appropriate
for age, as well as test-weights when necessary (Meier et al, 2000)

16. Discourage supplemental bottle feedings and encourage exclusive, effective breastfeeding.Supplemental feedings can interfere with the infant's desire to
breastfeed, increase the risk of allergies, and convey the subtle
message that the mother's breast milk is not adequate (American Academy
of Pediatrics, 1997; Chezem, Friesenl, 1998).

17. Acknowledge mother's feelings and support her decision to continue or choose an alternate plan.Mastering infant feeding is an important first step in mothering, and
the mother needs to be empowered so that she feels competent and
capable of making intelligent decisions (Brandt, Andrews, Kvale, 1998;
Mozingo et al, 2000).

19. If unsuccessful in achieving effective breastfeeding, help client accept and learn an alternate method of infant feeding.Once the decision has been made to provide an alternate method of
infant feeding, the mother needs support and education (Brandt, Andrews,
Kvale, 1998; Mozingo et al, 2000).

Multicultural

1. Assess for the influence of cultural beliefs, norms, and values on breastfeeding attitudes.The client's knowledge of breastfeeding may be based on cultural
perceptions, as well as influences from the larger social context
(Leininger, 1996).

2. Assess whether the client's concerns about the amount of milk taken
during breastfeeding is contributing to dissatisfaction with the
breastfeeding process.Some cultures may add semisolid food within the first month of life
as a result of concerns that the infant is not getting enough to eat and
the perception that "big is healthy" (Higgins, 2000; Bentley et al,
1999).

3. Assess the influence of family support on the decision to continue or discontinue breastfeeding.Women are the keepers and transmitters of culture in families. Female
family members can play a dominant role in how infants are fed
(Pillitteri, 1999).

4. Validate the client's feelings regarding the difficulty or dissatisfaction with breastfeeding.Validation lets the client know that the nurse has heard and
understands what was said and promotes the nurse-client relationship
(Stuart, Laraia, 2001; Giger, Davidhizer, 1991).

Client/Family Teaching

1. Provide instruction in correct positioning."Correct positioning is perhaps the most critical single measure for
getting breastfeeding off to a good start. Many problems can be
attributed to carelessness or inattention to this simple aspect of
breastfeeding" (Righard, 1998).

2. Reinforce and add to knowledge base regarding underlying problems and specific treatment measures.If mother understands rationale for recommended treatment, she may be
more likely to comply with recommendations and less likely to perceive
the problem as insurmountable (Cox, Turnbull, 1998; Susin et al, 1999).